What is the further treatment plan for a female patient with spondylosis at L4-L5 with intervertebral disc prolapse (IVDP) experiencing pain after undergoing interferential therapy (IFT) and initially treated with intramuscular (IM) Keterolac (Toradol), IM Tramadol, oral Pregabalin (Lyrica) 70mg, and intravenous (IV) Neurobion forte in 100ml normal saline (NS)?

Further Treatment Plan for L4-L5 Spondylosis with IVDP and Post-IFT Pain

Continue NSAIDs as the primary analgesic, optimize pregabalin dosing to 150 mg twice daily, discontinue tramadol due to lack of evidence in mechanical low back pain, and add structured physical therapy with thoracic spine mobilization while avoiding bed rest.

Immediate Medication Adjustments

Optimize Pregabalin Dosing

• Increase pregabalin from 70 mg to 150 mg twice daily (300 mg/day total), as this is the minimum effective dose demonstrated in neuropathic pain trials 1
• The current 70 mg dose is subtherapeutic; FDA-approved dosing for neuropathic pain starts at 150 mg/day divided into 2-3 doses, with efficacy demonstrated at 300-600 mg/day 1
• Monitor for dizziness and somnolence, which are the most common side effects 1

Continue NSAIDs as Primary Analgesic

• Maintain ketorolac or transition to oral NSAIDs (naproxen 500-550 mg twice daily or ibuprofen 600-800 mg three times daily) as first-line treatment for mechanical low back pain 2
• Ketorolac IM is indicated only for short-term use (≤5 days) for acute severe pain 3
• NSAIDs provide superior pain relief compared to acetaminophen for low back pain and are more effective than pregabalin for non-radicular mechanical pain 2

Discontinue Tramadol

• Stop tramadol immediately as there is insufficient evidence supporting its use in lumbar disc herniation without radiculopathy 4
• While tramadol shows efficacy in some neuropathic pain conditions, pregabalin and gabapentin have not demonstrated clear benefit in mechanical low back pain without radiculopathy 5, 6
• Reserve opioids only for severe, disabling pain uncontrolled by NSAIDs and only after reassessment 2

Discontinue Neurobion Forte

• Stop IV vitamin B complex (Neurobion forte) as there is no evidence supporting its use in acute disc-related pain management
• Focus resources on evidence-based interventions

Physical Therapy Interventions

Structured Mobilization Program

• Initiate upper thoracic spine mobilization from C7 to T6 as this approach has demonstrated resolution of radicular symptoms even with large disc herniations 7
• Perform cervical/lumbar extension exercises with prior voluntary thoracic spine extension 7
• Avoid bed rest; advise the patient to remain active as bed rest is less effective than activity for acute and subacute low back pain 2

Activity Modification

• Provide specific posture advice and ergonomic modifications 7
• Encourage continuation of daily activities within pain tolerance 2

Reassessment Timeline and Red Flags

Short-Term Follow-Up (1-2 Weeks)

• Reassess pain intensity using a numerical rating scale (0-10) 2
• Evaluate for progressive neurologic deficits: new or worsening motor weakness, saddle anesthesia, bowel/bladder dysfunction 2
• If progressive neurologic deficits develop, obtain urgent MRI and neurosurgical consultation 2

Medium-Term Evaluation (4 Weeks)

• If pain persists despite optimized NSAIDs and pregabalin at 300 mg/day, consider adding duloxetine 30 mg daily for one week, then increase to 60 mg daily 8
• Duloxetine combined with pregabalin targets different pain mechanisms for synergistic effect 8
• Treatment is considered successful if pain reduces by 30% or more from baseline 8

Long-Term Management (Beyond 4 Weeks)

• If inadequate response after 4 weeks at maximum tolerated doses, refer to pain specialist or spine surgeon 8
• Consider MRI if patient becomes a candidate for epidural steroid injection or surgical intervention 2

Alternative Medication Options if Current Regimen Fails

Second-Line Agents

• Tricyclic antidepressants (nortriptyline or desipramine starting at 10-25 mg at bedtime, maximum 75 mg/day) for chronic pain if duloxetine is ineffective 8
• Obtain screening ECG before starting tricyclics due to cardiac toxicity risk 8
• Gabapentin may be considered as an alternative to pregabalin, with moderate evidence for improved mobility in low back pain, though data is limited 5

Topical Adjuncts

• Lidocaine 5% patch can be added to localized areas of pain with minimal systemic absorption 8

Critical Pitfalls to Avoid

• Do not continue tramadol long-term without clear radicular or neuropathic component, as evidence does not support its use in mechanical disc disease 4
• Do not use pregabalin at subtherapeutic doses; the 70 mg dose is below the minimum effective range 1
• Do not prescribe prolonged bed rest, which worsens outcomes compared to remaining active 2
• Do not delay imaging if red flags develop: progressive weakness, cauda equina symptoms, or suspicion of infection/malignancy require urgent MRI 2
• Do not use ketorolac IM beyond 5 days due to increased risk of adverse events 3